PPT

Report
The new UN interagency maternal
mortality estimates
Agbessi Amouzou and Holly Newby
Data & Analytics Section, DPS, UNICEF
1 May 2014
 Will be released on Tuesday, 6
May 2014
 Levels and trends of maternal
mortality between 1990 and
2013 for 183 countries
 Includes MMR, lifetime risk of
maternal death and numbers of
maternal deaths
 Will replace current UN
interagency estimates pertaining
to 2010
Outline of the Presentation
 Why UN Inter-Agency estimate of maternal
mortality
 Summary of issues in maternal mortality
measurement
 How the UN Inter-Agency estimates are
produced
 Highlights of new estimates
WHY UN INTER-AGENCY
ESTIMATES?
Why Inter-Agency MM Estimates?
 MMR is key indicator for MDG 5
 Global monitoring and reporting requires a harmonized
measure of MMR that is comparable across countries
 Need to obtain a measure that has same reference year
across all countries
 Maternal mortality is challenging to measure
 Similar initiative is done for under-five mortality (see
www.childmortality.org)
Maternal Mortality Estimation
Interagency Group (MMEIG)
The UN interagency estimates are produced by
the Maternal Mortality Estimation Interagency
Group (MMEIG):
•
•
•
•
•
WHO (Lead)
UNICEF
UNFPA
The World Bank
Lead technical consultant (Leontine Alkema, National
University of Singapor)
• Technical Advisory Group
MATERNAL MORTALITY MEASUREMENT
Definitions
Definition
Implications
Maternal death
The death of a woman while pregnant
or within 42 days of termination of
pregnancy, irrespective of the duration
and site of the pregnancy, from any
cause related to or aggravated by the
pregnancy or its management but not
from accidental or incidental causes.
Pregnancy-related death
The death of a woman while pregnant
or within 42 days of termination of
pregnancy, irrespective of the cause of
death.

Death must be attributed directly or
indirectly to pregnancy or childbirth

Requires medical certification or
verbal autopsy

Cannot be obtained through surveys or
censuses

No deaths beyond 42 days due to
pregnancy complications accounted for

Cause of death certification not
needed
Can be obtained through surveys
or censuses

UN Interagency maternal mortality estimates conform to the definition of maternal death
Sources of maternal mortality data and
their limitations
 Maternal mortality data can come from a
variety of sources:
– Vital registration
• Considered gold standard
• Good in only about a third of
countries
• Extensive under-reporting
and misclassification
• Even in countries with
complete vital registration,
maternal deaths may be
underreported by a factor of
1.5 – 3.0
Sources of maternal mortality data and
their limitations
 Maternal mortality data can come from a
variety of sources:
– Vital registration
– Household surveys (sisterhood method)
• Pregnancy-related deaths
• MMR very imprecise, large
confidence intervals
• Doe not produce recent
estimate: MMR refers to 7 to
9 years in the past
Sources of maternal mortality data and
their limitations
 Maternal mortality data can come from a
variety of sources:
– Vital registration
– Household surveys (sisterhood method)
– Censuses
• Pregnancy-related deaths
• Conducted every 10 years
• Need adjustment for completeness
of births and deaths
Sources of maternal mortality data and
their limitations
 Maternal mortality data can come from a
variety of sources:
– Vital registration
– Household surveys (sisterhood method, etc.)
– Censuses
– Reproductive-age mortality studies (RAMOS)
• Complicate, time-consuming and
expensive
• Under-report of maternal deaths
• Under report of number of live
births
Sources of maternal mortality data and
their limitations
 Maternal mortality data can come from a
variety of sources:
– Vital registration
– Household surveys (sisterhood method, etc.)
– Censuses
– Reproductive-age mortality studies (RAMOS)
– Verbal autopsy
• Misclassification of cause of
death
• Under report of maternal
deaths
• Recall issues
Sources of maternal mortality data and
their limitations
 Maternal mortality data can come from a
variety of sources:
Bottom line:
– Vital registration
 Each
source surveys
has advantages
limitations.
– Household
(sisterhoodand
method,
etc.)
 Measurement
is challenging regardless of
– Censuses
source.
– Reproductive-age mortality studies (RAMOS)
 There
is
need
to
adjust
and
harmonize
– Verbal autopsy
available data for cross country
comparability and global reporting
Issues to keep in mind
 Survey estimates of MMR are averages over periods
of 7 or 9 years in the past, so not comparable to UN
Interagency estimates
 MMR generally have large uncertainty ranges
 Maternal death is a rare event; MMR is expressed in
per 100,000 live births and therefore creates a false
sense of precision
– 300/100,000 = 0.30/100
– 330/100,000 = 0.33/100
MMR of 300 may not
be different from
MMR of 330
Trend Estimation from Sibling Histories
with 95% Confidence Intervals (Namibia)
600
500
400
300
200
The 2007 MMR
refers to period
1998 -2007
100
0
1985
1990
1995
Year
1992 DHS
2007 DHS
2000
2005
2000 DHS
Estimates are averages over long periods (here 7 or 9 years) and 95%
confidence intervals are large
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010
Trend Estimation from Sibling Histories
with 95% Confidence Intervals (Namibia)
600
500
400
300
200
100
0
1985
1990
1995
Year
1992 DHS
2007 DHS
The 2000 MMR has
95%CI ranging from
2000 90 to 450
2005
2000 DHS
Estimates are averages over long periods (here 7 or 9 years) and 95%
confidence intervals are large
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010
Trend Estimation from Sibling Histories
with 95% Confidence Intervals (Namibia)
600
500
400
300
200
100
0
1985
1990
1995
Year
Note2000
that this2005
is at the
1992 DHS
2000 DHS
national
level!
It’s not possible
2007 DHS
to disaggregate by region or
other
like
Estimates are averages over long periods
(here 7characteristics
or 9 years) and 95%
confidence intervals are large
household wealth!
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010
HOW ARE THE UN INTER-AGENCY
ESTIMATES DONE?
Source of data for the 2013 MMR estimates
Group
Source of maternal
mortality data
Number of
countries/
territories
% of
% of births
countries/
in 183
territories in countries/te
each category rritories
covered
A
Civil registration
characterized as complete,
with good attribution of
cause of death
67
37
17
B
Incomplete civil registration
and/or other types of data
96
52
81
C
No national data on
maternal mortality
20
11
2
183
100
100
Total
General methodology of estimation
Little change from methodology used
for 2010 estimates
1. Compile and review all available nationally
representative maternal mortality data
2. Adjust available maternal mortality data for
misclassification and underreporting
General methodology of estimation
3. Use one of two approaches depending on country
– Countries with adequate civil registration data
• Calculate MMR directly with adjusted
– All other countries:
• Use multilevel linear regression model
• Covariates: GDP, general fertility rate and skilled attendant at
birth
• Separate model component for AIDS deaths that are indirect
maternal deaths
4. Compute uncertainty ranges through simulations
Methodological changes from the
2010 estimates?
 Increased data availability
– 5% increase in available data
 Update in the estimate of female deaths in the
reproductive age by WHO
 Update of series of live births and general
fertility rates from World Population Prospects
 Update in AIDS adjustment parameters
Methodological changes from the
2010 estimates?
 Data availability
– 5% increase in available data
 Update in the estimate of female deaths in the
reproductive age by WHO
 Update of series of live births and general
fertility rates from World Population Prospects
 Update in AIDS adjustment parameters
Little change from methodology used
for 2010 estimates
Review process
 Reviewed by the Technical Advisory Group
with experts from academic institutions:
Harvard University, Johns Hopkins University,
University of Aberdeen, and others
 Country consultation led by WHO allowed
countries to provide feedback and provide
new data
STOP!
 The 2013 UN interagency estimates REPLACE
the previous estimates and should not be
compared or interpreted together with them
 The 2013 estimates are NOT comparable to
estimates from other sources
Maternal mortality estimates generated by
countries
 At the global level, we use the interagency estimates for MDG
reporting and official monitoring
 UNICEF presents both nationally reported estimates and UN
interagency estimates in State of the World’s Children
TABLE 8
Trends in Maternal Mortality Ratio
(Embargoed until May 6, 2014)
By UNICEF regions
1200
940
990
1000
610
1990
380
430
2005
12
11
15
270
210
300
230
36
27
65
140
93
85
170
100
74
0
200
140
110
440
550
190
200
Embargoed until May 6, 2014 ---------------------280
400
510
600
680
800
2013
Source: Trends in Maternal Mortality: 1990-2013 (WHO, UNICEF, UNFPA, World Bank)
Resources
More information on new estimates available (from
May 6) at:
 Data.unicef.org
 Complete methodological details and all data available on:
www.who.int/reproductivehealth/publications/monitoring/xxxxxxxxx/en/ind
ex.html and MME Info: www.maternalmortalitydata.org
 We are in process of updating the MMEIG website MM Info
(maternalmortalitydata.org)
To be released on
6 May 2014!
Contacts
Agbessi Amouzou
[email protected]
Holly Newby
[email protected]

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